Clinical features and prognosis of severe scorpion envenomation in children.

BACKGROUND: Scorpionism is endemic and represents a real public health problem in Morocco. The most dangerous arthropod in the central area is Androctonus mauretanicus (Am) scorpion. Its venom can be lethal, especially for children. This study aimed to determine a clinico-epidemiological profile of severe scorpion envenomation among children and identify risk factors for mortality. METHODS: This retrospective cohort study included 606 children admitted for severe scorpion envenomation (SSE) from January 2010 to July 2015 in the Pediatric Intensive Care Unit (PICU) of Mohammed VI Teaching Hospital. RESULTS: The mean age of envenomed children was 6.3 ± 4.2 years. Seventy-four percent of them came from rural settings. Envenomation occurred mostly during the summer months and 78.4% of stings were nocturnal. The time between the sting and evaluation was greater than 2 h in 83% of cases. Bivariate analysis indicated that from 1 to 24 months of age (P = 0.001), hyperthermia (P = 0.022), episodes of diarrhea (P < 0.001), tachycardia (P < 0.001), abdominal distention (P < 0.001), skin marbling (P < 0.001), signs of respiratory distress (P < 0.001), irritability (P < 0.001), generalized seizures (P = 0.053), and Glasgow Coma Score (GCS) of 3 to 9 (P < 0.001) were significantly correlated with mortality. On multivariate analysis, diarrhea (P = 0.007), skin marbling (P = 0.006), and respiratory distress (P = 0.002), and GCS 3-9 (P = 0.007) were found to be independent risk factors for mortality in our patient population. CONCLUSIONS: Children are at high risk of developing serious complications, even death, from severe scorpion envenomation. Here we identified multiple factors that appear to increase the mortality risk in children after scorpion envenomation, including previously described central nervous system alterations.

Coronavirus disease 2019 (COVID-19) pathogenesis: a concise narrative review.

SARS-CoV-2 is the third zoonotic coronavirus. Since December 2019, it has spread through the globe and infects more than four million patients (as of May 10th, 2020). The disease was named coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO). It involves many organs and systems in the human organism. We aimed to describe the pathogenesis of the COVID-19.

What Open-Lung Biopsy Teaches Us about ARDS in COVID-19 Patients: Mechanisms, Pathology, and Therapeutic Implications.

Difficulties have risen while managing Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19, although it meets the Berlin definition. Severe hypoxemia with near-normal compliance was noted along with coagulopathy. Understanding the precise pathophysiology of this atypical ARDS will assist researchers and physicians in improving their therapeutic approach. Previous work is limited to postmortem studies, while our report addresses patients under protective lung mechanical ventilation. An open-lung minithoracotomy was performed in 3 patients who developed ARDS related to COVID-19 and were admitted to the intensive care unit to carry out a pathological and microbiological analysis on lung tissue biopsy. Diffused alveolar damage with hyaline membranes was found, as well as plurifocal fibrin microthrombi and vascular congestion in all patients' specimens. Microbiological cultures were negative, whereas qualitative Reversed Transcriptase Polymerase Chain Reaction (RT-PCR) detected SARS-CoV-2 in the pulmonary parenchyma and pleural fluid in two patients. COVID-19 causes progressive ARDS with onset of severe hypoxemia, underlying a dual mechanism: shunt effect through diffused alveolar damage and dead space effect through thrombotic injuries in microvascular beds. It seems reasonable to manage this ventilation-perfusion ratio mismatch using a high dose of anticoagulant combined with glucocorticoids.

Management of Severe COVID-19 in Pregnancy.

The scarcity of data concerning pregnant patients gravely infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) makes their management difficult, as most of the reported cases in the literature present mild pneumonia symptoms. The core problem is laying out evidence on coronavirus's implications on pregnancy and delivery, as well as vertical transmission and neonatal mortality. A healthy 30-year-old pregnant woman, gravida 6, para 4, at 31 weeks of gestation, presented severe pneumonia symptoms promptly complicated with premature rupture of membranes (PROM). A nasopharyngeal swab returned positive for SARS-CoV-2 using reverse transcription polymerase chain reactions (RT-PCR). The parturient underwent a cesarean delivery. This paper is an attempt to outline management of the critical condition of COVID-19 during pregnancy.

A successful use of therapeutic plasma exchange in a fulminant form of acute fatty liver of pregnancy.

Acute fatty liver of pregnancy (AFLP) continues to raise special concerns since its first post-mortem description by Sheehan in 1940. While early diagnosis and expedite delivery are the cornerstone of management, this condition remains fatal for both mother and fetus. Acute fulminant liver failure is the most serious and life-threatening AFLP-related complication and can require liver transplant despite aggressive supportive management. In lieu of transplant, therapeutic plasma exchange (PE) has emerged as a life-saving alternative and has, in few reports, demonstrated efficacy for the reversal of this dangerous condition. Here we present a case report of a patient diagnosed with fulminant liver failure complicating an AFLP and progressed to severe hepatic encephalopathy who was successfully treated with five rounds of plasma exchange.

Chronic Myeloid Leukemia and Cesarean Section: The Anesthesiologist's Point of View.

BACKGROUND: Chronic Myeloid Leukemia (CML) is a myeloproliferative neoplasm related to chromosomal reciprocal translocation t(9;22). Tyrosine kinase inhibitors (TKIs) such as imatinib have drastically revolutionized the course and the prognosis of this hematologic malignancy. As we know, the association pregnancy-CML is an infrequent situation. Also the use of TKI in pregnant women is unsafe with a lack of alternatives and effective therapeutic options. Thus its cessation during gestation puts those patients at high risk of developing blast crisis characterized by poor outcomes. CASE REPORT: A 37-year-old pregnant woman, gravida 2, para 2, with a previous cesarean section in 2011, presented to the obstetric unit. Her medical past revealed that she is a newly diagnosed patient with CML managed by TKI during her preconception period. Due to the perilous use of TKI during her pregnancy, a switch to interferon-α administration was adopted. But after the completion of 36 weeks of gestation, disease progression (relapse with blast crisis), attested by biological worsening, a white blood cell count = 245000/mm3 with 32% blasts in the peripheral blood, urged the medical team to opt for cesarean delivery. She underwent general endotracheal anesthesia without any perioperative incidents and gave birth to a healthy newborn. Ten days later, the patient was started on TKI. DISCUSSION: Although data on this specific and challenging situation are limited, this case highlights the difficulties encountered by the anesthesiologists when choosing the accurate anesthetic strategy and how important it is to weigh the risks and benefits inherent to each technique. Above all, taking into consideration the possible central nervous system (CNS) contamination by circulating blast cells when performing spinal or epidural approach is primordial. This potential adverse event (CNS blast crisis) is extremely scarce but it is responsible for high rates of morbidity and mortality.

Risk factors for eclampsia in pregnant women with preeclampsia and positive neurosensory signs.

OBJECTIVE: In Morocco, eclampsia remains the second major cause of maternal mortality. Conventionally, patients with preeclampsia and neurosensory signs (NSS) (e.g., headaches and hyperreflexia) are considered at high risk of worsening and progressing to eclampsia. However, this specific population is heterogeneous in terms of eclampsia occurrence. We aimed to identify the risk factors for the development of eclampsia in women with preeclampsia presenting with NSS at admission. MATERIALS AND METHODS: We performed a single-center, retrospective case-control study of patients with preeclampsia with positive NSS from January 1st, 2012 through December 31st, 2015, to investigate predictive factors for eclamptic seizures. The case patients were pregnant women with severe preeclampsia who had NSS before developing eclampsia. Control subjects were those with positive NSS without the development of seizures during their hospital stay. One hundred-thirty eight patients with eclampsia and 272 control patients were enrolled. RESULTS: Univariate analysis revealed that eclampsia was more likely to develop in patients with the following risk factors: maternal age ≤25 years (χ2=9.58, p=0.002), primiparity (χ2=6.38, p=0.011), inadequate prenatal care (χ2=11.62, p=0.001), systolic hypertension ≥160 mmHg (χ2=15.31, p<0.001), diastolic hypertension ≥110 mmHg (χ2=5.7, p=0.017), generalized acute edema (χ2=14.66, p<0.001), hematocrit <35% (χ2=11.16, p=0.001), serum creatinine >100 µmol/L (χ2=13.46, p<0.001), asparate aminotransferase (AST) >70 IU/L (χ2=10.15, p=0.001), and thrombocytopenia (χ2=22.73, p<0.001). Additionally, independent predictive factors for eclampsia in multivariate analysis included inadequate prenatal care [odds ratio (OR), 8.96 [95% confidence interval (CI): 3.9-20.5], p<0.001), systolic blood pressure ≥160 mmHg (OR, 3.130 [95% CI: 1.342-7.305], p=0.008), thrombocytopenia with a platelet count <50.000 (OR, 13.106 [95% CI: 1.344-127.823], p=0.027), AST ≥70 IU (OR, 3.575 [95% CI: 1.313-9.736], p=0.007), and elevated liver enzymes level, and low platelet count (ELLP) syndrome, which is an incomplete variant of HELLP syndrome (H for hemolysis) (OR, 5.83 [95% CI: 2.43- 13.9], p<0.001). CONCLUSION: This work highlights two major risk factors in this patient population, inadequate prenatal care and ELLP syndrome, which can help in the early identification of patients at highest risk of developing eclampsia and guide preventive measures.

Posterior Reversible Encephalopathy Syndrome in a Child Stung by Androctonus mauretanicus Scorpion.

Posterior reversible encephalopathy syndrome (PRES) after scorpion sting was very rarely reported in literature. This is an authenticated report of PRES occurring, in a 3-year-old previously healthy girl, as a complication of the Moroccan Androctonus mauretanicus sting. According to the available and recent data, we attempt to discuss the potential mechanisms leading to this neurologic disorder and to determine the possible cause-effect relationship between scorpion venom and its development.

The ability of two scoring systems to predict in-hospital mortality of patients with moderate and severe traumatic brain injuries in a Moroccan intensive care unit.

AIM OF STUDY: We aim to assess and to compare the predicting power for in-hospital mortality (IHM) of the Acute Physiology and Chronic Health Evaluation-II (APACHE-II) and the Simplified Acute Physiology Score-II (SAPS-II) for traumatic brain injury (TBI). PATIENTS AND METHODS: This retrospective cohort study was conducted during a period of 2 years and 9 months in a Moroccan intensive care unit. Data were collected during the first 24 h of each admission. The clinical and laboratory parameters were analyzed and used as per each scoring system to calculate the scores. Univariate and multivariate analyses through regression logistic models were performed, to predict IHM after moderate and severe TBIs. Areas under the receiver operating characteristic curves (AUROC), specificities and sensitivities were determined and also compared. RESULTS: A total of 225 patients were enrolled. The observed IHM was 51.5%. The univariate analysis showed that the initial Glasgow coma scale (GCS) was lower in nonsurviving patients (mean GCS = 6) than the survivors (mean GCS = 9) with a statistically significant difference (P = 0.0024). The APACHE-II and the SAPS-II of the nonsurviving patients were higher than those of the survivors (respectively 20.4 ± 6.8 and 31.2 ± 13.6 for nonsurvivors vs. 15.7 ± 5.4 and 22.7 ± 10.3 for survivors) with a statistically significant difference (P = 0.0032 for APACHE-II and P = 0.0045 for SAPS-II). Multivariate analysis: APACHE-II was superior for predicting IHM (AUROC = 0.92). CONCLUSION: The APACHE-II is an interesting tool to predict IHM of head injury patients. This is particularly relevant in Morocco, where TBI is a greater public health problem than in many other countries.

Severe envenomation by Cerastes cerastes viper: an unusual mechanism of acute ischemic stroke.

Cerebral complications after snake bites--particularly ischemic complications--are rare. Very few cases of cerebral infarction resulting from a viper bite have been reported, and we call attention to this uncommon etiology. We discuss 3 authenticated reports of acute ischemic cerebrovascular accidents after 3 typical severe envenomations by Cerastes cerastes vipers. The 3 patients developed extensive local swelling and life-threatening systemic envenomation characterized by disseminated intravascular coagulopathy, increased fibrinolysis, thrombocytopenia, microangiopathic hemolytic anemia, and acute renal failure. This clinical picture involved atypical neurologic manifestations. These patients had either low Glasgow Coma Scale (GCS) or hemiparesis within hours to 4 days after being bitten, and they were found to have computed tomographic evidence of single or multiple ischemic (nonhemorrhagic) strokes of small- to large-vessel territories of the brain. One patient had good clinical recovery without neurologic deficits. Thrombotic complications occurred an average of 36 hours after being bitten, and their importance depends on the degree of envenomation. The possible mechanisms for cerebral infarction in these cases include generalized prothrombotic action of the venom (consumptive coagulopathy), toxin-induced vasculitis, and endothelial damage.